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APPLICATION FOR SANITATION PERMIT Permit No. t A�A (Complete in Duplicate) Date Issued Applic&ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance withfCounty Ordinance No. 549. , JOB ADDRESS AND LOCATION_______---4- ---- 4'x_______________ -----------------------_____ --------------------------- • - -•---------------------------------------------------- Owner's Name--------- � .� � /� ----- -----------�--•-------------------------------------------- ------------ ----- Phone----- ----------------------•------- 5 (9 Address �{ �+ ----- ---------•---• L.� ••-----------------------•-•-------•--•---•-•-••----------------•---•--------•--------------....... C.-_ DD/ Name Ir ------------------------------------- --------------- Contractor's Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel p Other ❑ Number of living units: -------- Number of bedrooms _______ Number of baths -------- Lot size ____________________________________________________________ Water Supply: Public system ❑ Community system ❑ Private ❑ -Depth to Water Table -------- ft. Character of soil to a depth of 3 feet:" Sand ❑ Gravel ❑ Sandy Loam ❑ Clay.Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction, Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well___•7-•_`_ v-----Distance from foundation__._-/'d--------Material___e_e-__-_ �� [? No—of compartments_______—'W- c.�� - ----- ---Size-----'5 Liquid Liquid depth-----Z --------Ca aci g-------------- Disposal Field: - pistance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line--------------_- ❑ r of lines Length of each line Width of trench T e of filler material------------------------ Depth of filter material-----------------------Total length-----_---------•----.--------------------- Seepage Pit: istance to nearest well______________________Distance from foun'dation-------------------.Distance to nearest lot line------ ----------- 6 ❑ r of pits--------------- ------Lining material--------------------- -Size: Diameter-------------- ----- -..Depth------------- Cesspool: Distance from nearest-well-----------------Distance-from foundation........... ---- material------------------------------------- V) ❑ Size: Diameter------- ----------------------------- Depth------- ------------------ •-- ---------------------Liquid Capacity-.--------------------------gals. Privy: Distance from neoest well._..r__-..____.____________________--;-------Distance from nearest building------------------------------------------r% Distance to nearest lot line'---' - k--1-- ------------------------------------------------- ----------•----------- --- �- ---------•-------------- Remodeling and/or repairing (describe):-------- -------- ---------------------=----------------------------------=------------._.._.._.------------------------•---•• . ----------------------------•---------------------•---------------------------------- -----------------------------------------_-----------------•---•-=--•--------------------------...-------------------•-------- -- ----------•-------•-------•-------------------------------------• ---------------------------------------------------....... ---•-----------•----------------------------------•-------------------------------- r --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------- I hereby certif that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat aw , and rules*and regulations of the San Joaquin Local Health District. (Signed - --�r-------------------------------------------------- ---- --(O(Owner and/or Contractor) By. ------------------------(Ti#Ie} (Piot plan, showing size of lot, location of system in re ation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ----- - ---------- -------- DATE . . ----•------------------------------ REVIEWEDBY -------------------- --- -- -------------- ---------------------------------------------------... DATE---- BUILDING PERMIT ISSUED-------------------------- -- - DATE ---------------------- Alterations and/or recommendations:__..____________ __ _ ----- / --- ----------- -•---------------------- ---------------------------------------- --- ... ---- - ---------. ---- ------------•--------------------------- FINAL INSPECTION ------ -------------------- Date:...... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 145446 ATW000 12-54 t